Inquest finds neglect contributed to death of PC Sharon Houfe

Senior Coroner, Professor Paul Marks this week concluded that Sharon Houfe died as a result of suicide contributed to by neglect. Sharon took her own life on Friday 29 April 2016.

Sharon was a serving police officer with Humberside Police, much respected and distinguished by her colleagues and community, and had been awarded an MBE in 2014 for her services to community policing.

Mike Ruston, Sharon’s brother-in-law, said: “Sharon was an understanding, non-judgemental arm of the law. She was down-to-earth, no airs and graces never arrogant or materialistic. She adored her role as a Police Officer.

“Friday 29th April will remain lodged in our minds, for the rest of our lives. The day that brought much sadness to a once fun-loving family. Sharon cared for everyone.”

In the week before her death, Sharon became acutely unwell with depressive illness and some psychotic features. Sharon and her family had eight interactions with mental health services at Humber NHS Foundation Trust during that week, two via Hull Infirmary’s A&E Department, the others by telephone and one arranged face-to-face assessment. She had previously been in contact with a force occupational health officer, who had been assisting her over several months.

Despite voicing suicidal intentions, none of the mental health nurses involved escalated her case to psychiatric doctors. Sharon had also asked to be sectioned and said she needed putting away.

Contact with mental health services between 23 and 26 April 2016, where staff failed to refer on her case “due to poor clinical judgements”, were found by the Coroner to have been missed opportunities, which if they had been taken, would on the balance of probabilities have avoided her death.

Sharon was due to have a face-to-face assessment with mental health nurse Mark Fratson at Miranda House in Hull on 27 April 2016. When she attended with her partner, Mr Fratson had made a decision that a further assessment was not required (a reassessment was mandated under the Trust’s policy), and he cancelled the meeting room booked and saw them in a corridor to simply provide them with copies of an assessment earlier on in the week, and to confirm the plan was for counselling with the “Let’s Talk” service. Sharon was reportedly devastated by this decision and took the view “no one can help me now “.

The failure by Mr Fratson to carry out an assessment was found by the Coroner to be a complete dereliction of duty, and after considering the strict criteria on coronial rulings, found that this missed opportunity constituted neglect. Mr Fratson has already been referred by the Trust to the Nursing and Midwifery Council, whose investigation is ongoing.

As Sharon’s condition continued to deteriorate, her family rang the Humber NHS Foundation Trust crisis team on the evening of 28 April 2016, but as Sharon was unable to speak to them herself, they advised they could not assist. The thirteen minute call is acknowledged by the Trust, but no records of it were made, and all four staff on duty either said they had not taken the call or had no memory of doing so.

Sharon appeared to improve the following morning. Despite close attention from her family, after being left at home for less than an hour whilst a family member returned home for a change of clothes, Sharon hanged herself.

Speaking about the investigation into circumstances around Sharon’s death, Mike Ruston said: “Although we may never know what was troubling Sharon. The purpose of an inquest is to learn and to prevent the pain for other families having to go through the pain our family has had to go through… We will never stop loving Sharon, she still lights up our lives.”

Sharon’s son, mother, partner, siblings and wider family have been devastated by her tragic death.

Neglect Conclusion

In an inquest, the “verdict” is now known as a “conclusion” because Coroners reach conclusions about a death – a verdict is something that would be delivered in a criminal trial. Neglect is a very uncommon conclusion because it has a very specific legal meaning. In order to return a conclusion of neglect a Coroner has to be satisfied that there was a gross failure to provide basic care to a vulnerable and dependant person. The Coroner concluded that Sharon had been able to take her own life because, without justification, a nurse did not carry out any assessment of her.

Switalskis continue to support Sharon’s family.

You should seek legal advice if you think that the death of a loved one may have been caused by medical error or mistake. The medical negligence team at Switalskis can help you with this, and can offer advice and assistance if the coroner decides to hold an inquest. Call us on 0800 138 0458 or send us a message via the contact form below.

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Help with mental health issues:

Samaritans
116 123
https://www.samaritans.org/

Mind InfoLine
0300 123 3393
https://www.mind.org.uk/